Text | Wu Yu
"Since eating XX, my waist is not sore, my legs don't hurt, and I have the strength to walk." This slogan, which has been familiar to generations, also laid the foundation for their understanding of osteoporosis and its connection to "calcium deficiency".
Therefore, for osteoporosis, many Chinese first reaction is "calcium deficiency", thinking that calcium supplementation is good, this idea underestimates the risk of osteoporosis, and eating some calcium tablets can not fundamentally change the problem of osteoporosis.
More importantly, the problem caused by osteoporosis is not as simple as back pain. Academician Yuan Longping died in the first half of this year, and two months before his death, he just fell, and many medical experts lamented afterwards that Yuan Longping's death and wrestling may be inseparable.
In the folk, a little experienced elders know that the most feared thing for the elderly is wrestling, and they often die soon after the fracture of a fall. The cause of fractures is often because of osteoporosis.
The dangers of wrestling in the elderly are often fatal. (Photo/Visual China)
<h1 class="pgc-h-center-line" data-track="14" > misunderstood "silent killer"</h1>
"Human bones are indeed composed of calcium and phosphorus, simply put, calcium deficiency will cause osteoporosis, but it does not mean that calcium is not loose without lack of bone." Zhang Zhenlin, director of the Department of Osteoporosis and Orthopedic Diseases at the Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, said that osteoporosis is caused by many reasons, not just calcium deficiency. Patients mistakenly think that calcium supplementation can be treated, eat a lot of calcium tablets or other ways to spontaneously supplement calcium, "calcium is still there, but not in the bones, ectopic calcification, calcium may go inside the arteries." ”
Young people are strong, fractures are not very dangerous diseases, bed rest for a period of time can be cured, but for the elderly, there is usually no obvious clinical manifestations in the early stage, but with the continuous loss of bone mass, there will be pain, spinal deformation and other symptoms, and even lead to fragile fractures - one of the most common and serious consequences of osteoporosis, which may mean that life is loaded with a countdown. Within one year of a hip fracture, known as the "last fracture of a lifetime," about 20% of patients will die from various complications such as thrombosis, and about 50% of patients will be disabled.
Osteoporosis should be understood as a disease, not a symptom or physiological phenomenon.
Osteoporosis (hereinafter referred to as "osteoporosis") refers to a systemic bone disease in which bone density and bone quality decrease and bone microstructure are destroyed due to various reasons, resulting in increased bone fragility, which is prone to fractures. Its incidence is closely related to age, and the number of people affected will continue to increase as the degree of aging in the country increases.
In 2018, the National Health Commission released the first epidemiological survey of osteoporosis in China. Data show that there are 80 million osteoporosis patients in China, of which postmenopausal women account for 90%. Due to hormonal changes in the body, the average woman loses 7% of her bone mass in the first year after menopause, and the incidence of osteoporosis increases significantly. One in three Chinese women over the age of 50 is sick, and the incidence is more than 50% in women over the age of 65. In 2015, the number of major fragility fracture cases in China has reached 2.69 million, and it is predicted that the number of cases will reach 5.99 million in 2050.
At present, the prevalence of patients over 50 years old in China is only 7.0%; the proportion of women over 50 years old who have undergone bone density testing is only 4.3%; the diagnosis rate of osteoporosis in patients who have developed fragile fractures is only about 2/3, and less than 1/4 of those who receive effective anti-osteoporosis drugs.
There are many drugs for the treatment of osteoporosis, such as estrogen, bisphosphonates, monoclonal antibodies and other drugs. However, more than 90% of patients with osteoporosis do not know that they have the disease, because in the early stage, many patients with osteoporosis do not have any symptoms. For elderly patients in the later stage, the fatality rate and disability rate are higher. Thus, in the mouth of clinicians, osteoporosis is likened to a "quiet killer."
In the case of no symptoms, the screening of osteoporosis can only resort to bone density detection, "if bone density decreases, bone mass loss, it is recommended to use drug intervention, considering the complexity of chronic diseases in the elderly, so now innovative drugs have good efficacy, low frequency of medication, few side effects, bone mass loss can be controlled quickly, does not increase the burden of medication in the elderly, and patients have good compliance and tolerance for it." Cheng Qun, director of the Osteoporosis Department of Huadong Hospital affiliated to Fudan University, said. However, due to the general lack of awareness of osteoporosis in China, the bone density detection rate is very low, and the standardized diagnosis and treatment rate is even lower.
"At present, less than 5% of people who come to do bone density tests are not more than 5%," Zhang Zhenlin said. He hopes that even healthy, asymptomatic people will go to bone density tests, especially in postmenopausal women and people who have undergone hormone therapy and other people with a high incidence of osteoporosis. He also stressed that people who have already suffered fragile fractures must be screened for bone pine.
Zhang Zhenlin and his team receive an average of thousands of outpatients per month.
However, most current medical packages do not include bone density tests, and the public has a very limited understanding of osteoporosis and does not take the initiative to check.
Sometimes, patients will act as a bridge, and patients who have been diagnosed will conduct science popularization to suspected patients, "A girl named Liu next door is 7 years younger than me." She was also osteoporosis, and she didn't know, so I told her and said you go to the hospital for a check-up. An elderly patient surnamed Huang in Hunan Province said. However, this individual and fragmented approach cannot fundamentally change the current situation of low examination rate and low treatment rate of osteoporosis in China.
Including screening, examination, referral, treatment and other measures, it is urgent to establish an efficient management system for osteoporosis patients that meets China's national conditions.
<h1 class="pgc-h-center-line" data-track="107" > difficult to regulate and sink the diagnosis and treatment system of the community</h1>
21 years ago, Zhang Zhenlin, who first came to Shanghai as a doctor from Ningbo, had to go to the community every week to publicize and popularize osteoporosis, and these efforts had a certain effect, "Osteoporosis patients will write poems to us and publish them in the auditorium of our hospital, which is a very touching thing." ”
But he gradually found that although this kind of publicity and science can play some role, but the treatment of symptoms can not cure the root cause, in addition to the on-site publicity can not reach more patients, the level of diagnosis and treatment of community hospitals also affects the treatment of osteoporosis patients.
"Bone pine patients go to the community hospital, some community doctors will give patients golden injections, cupping, physiotherapy, etc., these treatments may alleviate symptoms such as pain, but can not change the course of osteoporosis, nor can it prevent the occurrence of fragile fractures, I hope that in the treatment of the symptoms should also take into account the root cause, so that the elderly can get real benefits, the quality of life can be truly improved." Professor Cheng Qun, director of the Department of Osteoporosis at Huadong Hospital affiliated to Fudan University, said.
The belt commonly worn by the elderly has limited treatment for osteoporosis.
The lack of specialist doctors, chronic disease prevention and treatment management personnel are seriously insufficient, is an important reason for the low ability to diagnose and treat osteoporosis, "specialized outpatient clinics are very important, in the hospital doctors back and forth, affecting the effect of patient treatment, outpatient clinics to be fixed, in fact, equipped with certain basic examination measures and drugs is enough." ”
Therefore, Zhang Zhenlin, who is in the top three hospitals, started from the community hospital in Shanghai and began to explore how to strengthen the connection between the top three hospitals and the community hospitals, promote the development of bone pine specialist outpatient clinics in the community hospitals, open up the referral mechanism between the top three hospitals and the community hospitals, give full play to the power of the community hospitals, and radiate a wider range of the public. He and many colleagues went to the community hospital to train community hospital doctors, put the testing machine in the community hospital for doctors to use, "led a osteoporosis capacity building project under the Health Commission, piloted 4 units, everyone was very motivated, and later on this basis, almost 150 or so community hospitals established specialized outpatient clinics, long-term cooperation with us." ”
Overall, Shanghai has completed some infrastructure construction in community hospitals, many community hospitals basically have medicines, doctors can diagnose and treat, there are machines that can be screened, Zhang Zhenlin said, "This is the biggest change in Shanghai in the field of bone pine treatment in recent years, known as the Shanghai model." ”
But outside of first-tier cities such as Shanghai, the situation remains grim. Although the main position of osteoporosis should be in community hospitals, whether from the subjective or objective dimensions, many community hospitals in second- and third-tier cities are difficult to undertake the heavy responsibility of preventing osteoporosis, "We have successful cases in Shanghai, but this success cannot be replicated." ”
Zhang Zhenlin said that including community hospitals, many domestic hospitals still do not have the conditions to carry out bone density examination, most of the patients' treatment and long-term management are scattered in orthopedics, geriatrics, endocrinology, gynecology and other departments, the department does not have long-term stable management, patients do not know who to look for.
This condition often occurs even in tertiary hospitals, and at the same time, tertiary hospitals themselves are under overload.
On the one hand, patients tend to pile up in tertiary hospitals, and have not yet formed the subjective will and habit of long-term management of chronic diseases in the community; on the other hand, there are also many problems in the coordination between community hospitals and second- and third-level hospitals. In addition, the personnel, equipment, and drug allocation for specialized treatment cannot keep up, and it has also become a constraint to establish a linkage bone pine prevention and control system. "In the case of osteoporosis patients, the lower hospital can be referred to the higher hospital, and the patient can also be standardized management in the hospital. But this is also quite difficult to do, many community hospitals or first-level hospitals in the management of patients, there will be only to help patients alleviate symptoms, without really treating the disease or positive upward referral problems. Zhang Zhenlin said.
Cheng Qun said that these have fundamentally affected the prevention and treatment of osteoporosis, so like chronic diseases such as hypertension and diabetes, the establishment of a standardized diagnosis and treatment system is urgent, and only when the standardized diagnosis and treatment channel is unblocked, the incidence of fractures caused by osteoporosis will gradually decrease.
Once the standardized diagnosis and treatment of osteoporosis is realized, like other chronic disease management, community hospitals should be an important position for disease prevention and management.
In addition to capacity-building at the grassroots level, public education is also important. "The patient's concept should be changed", according to Zhang Zhenlin's experience, transferring patients from his hospital, it is relatively convenient and effective to manage in the community hospital, such as the establishment of patient health files, the community hospital is easier to do, "How many months did the patient do this bone density test?" When was the blood tested? Are you taking your medication on time? Are there regular visits every month? "These are the advantages of community hospitals rooted in the community, but only when the public awareness of medical treatment is raised, the advantages of community hospitals can be fully utilized."
In addition, osteoporosis has not yet been included in the prevention and treatment system of chronic diseases, which also affects the prevention and treatment of osteoporosis to a certain extent. At present, Shanghai and other regions can be reimbursed for osteoporosis drugs, but many provinces such as Shandong, Henan, etc., still can not be reimbursed, compared with myocardial infarction, stroke or breast cancer, fragile fractures caused by higher number of hospitalizations and costs, and the future will continue to grow with aging.
Severe osteoporosis greatly affects the patient's daily basic activities.
"Osteoporosis is not like a cold, it is a long-term disease, if not treated as soon as possible, osteoporosis patients often fracture, but will increase the burden of medical insurance payments." Zhang Zhenlin said.
<h1 class="pgc-h-center-line" data-track="108" > explore more diverse paths for osteoporosis prevention</h1>
In foreign countries, there is a precedent for the prevention and control system of osteoporosis. Since 2012, the International Osteoporosis Foundation (IOF) has been advocating the global rollout of the Fracture Liaison Service (FLS), a comprehensive system of post-fracture identification, registration, evaluation and treatment of patients to improve the detection, treatment and compliance of osteoporosis in fragile fracture patients and to reduce the incidence of secondary fractures.
On December 19, 2020, the "China Health Knowledge Dissemination Incentive Program (Bone Force Plan)--China Fragility Fracture Risk Patient Management Project" was officially launched. The project is jointly sponsored by the Institute of Science and Technology of the National Health Commission and the expert group of the Osteoporosis and Bone Mineral Salt Disease Branch of the Chinese Medical Association, and guided by the Disease Control Bureau of the National Health Commission, the China Health Education Center and the Office of the China Journalist Association. Up to now, dozens of relevant departments of medical institutions across the country have been included in the construction of pilot demonstration units of the "Bone Force Plan".
The "Bone Force Plan" aims to achieve optimal management of osteoporosis, continuously improve the benefits of osteoporosis patients, expand social attention and support, carry out standardized management around patients with high risk of fractures, explore diversified and individualized implementation paths, use the output of patient management projects, promote scientific exchanges and continuing education, help the development of disciplines in the field of osteoporosis, combine digital platforms, link up and down, and continue to transmit the concept of bone health.
From a broader perspective, the prevention and control of osteoporosis requires the joint participation of the government, medical institutions and the public, and Zhang Zhenlin believes that the basis for establishing a bone pine prevention and treatment system is the improvement of patients' awareness of active medical treatment. Similar to rheumatoid arthritis, diabetes, etc. that require lifelong medication, osteoporosis is also a long-term disease, "bone floss fractures and traumatic fractures are different, due to decreased bone density, fractures caused by osteoporosis will occur repeatedly even if there are multiple surgeries." ”
Screening is also a necessary part of the diagnosis and treatment of osteoporosis, a few years ago, Zhang Zhenlin's team carried out screening covering more than 14,000 people in 10 communities in Shanghai, and found that 17% of them had fractures of 1 to 2 vertebrae of different degrees, and these people were all patients with osteoporosis.
In 2017, the General Office of the State Council issued the "Notice of China's Medium- and Long-term Plan for the Prevention and Treatment of Chronic Diseases (2017-2025)" proposed to include bone density testing projects in the routine physical examination of people over 40 years old, with the improvement of patient awareness, screening for osteoporosis, fragile fractures and other screenings will become more and more popular, which can greatly reduce the clinical burden of osteoporosis and save the cost of the medical system.
In view of the shortcomings in the diagnosis, treatment and management of bone pine disease and fracture prevention and treatment, some regions have begun to explore and build a management system for the prevention and treatment of bone pine disease from the specific conditions of various places. For example, Shanghai, Zhejiang and other places have carried out two-way referral and prevention paths between bone pine prevention and treatment communities and corresponding top three hospitals, and the payment system is also being implemented and improved.
In Shanghai, Zhang Zhenlin's team has explored a better referral model, that is, regular training for community doctors every year, the establishment of osteoporosis clinics, so that patients know who to look for, and then through the vigorous promotion of community osteoporosis clinics, so that more patients can easily see a doctor and receive treatment.
Ningbo City, Zhejiang Province, has also further explored this, relying on the Ningbo Municipal Clinical Guidance Center for the Prevention and Treatment of Osteoporosis, Ningbo City has carried out the prevention and treatment of osteoporosis, and built a "Ningbo Osteoporosis and Fragility Fracture Prevention and Control Network" covering Ningbo City, realizing the whole chain management of osteoporosis prevention, screening, diagnosis, treatment, referral, follow-up and self-management. In Haishu District, Ningbo City, 733 cases of osteoporosis have been screened, of which 384 have been confirmed, and the whole chain management has been implemented, and by the end of 2020, 194 patients have completed one or more follow-up visits.
The establishment of osteoporosis prevention and treatment system is a long-term process, from the current doctors and experts spontaneous "folk experience", the establishment of osteoporosis prevention and treatment system, the need to establish community hospitals and higher-level hospitals between the information referral channel, the integration of orthopedics, endocrinology, geriatrics, obstetrics and gynecology and other cross-disciplinary diagnosis and treatment forces, to achieve the "cross-disciplinary" standardized management of diseases, but also need the government, medical institutions and patients tripartite participation. It is believed that through the establishment of popular science publicity, graded diagnosis and treatment and prevention system, one day, the harm of osteoporosis can be reduced, tragedies can no longer be repeated, and patients can be the first responsible person for their bone health.
October 20 is World Osteoporosis Day, and Southern Weekend launched a special plan "Proud Bone Life · Live up to the years", record the real life of osteoporosis patients, and see one of thousands of them. Click to watch the video to focus on the bone health of middle-aged and elderly women.
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